What barriers to care exist for American Indian individuals in rural communities?
Clinical Applications
Dr. Schwarzenberger is the former physician editor of DermWorld. She interviews the author of a recent study each month.
By Kathryn Schwarzenberger, MD, October 1, 2019
In this month’s Clinical Applications column, Physician Editor Kathryn Schwarzenberger, MD, talks with Arash Mostaghimi, MD, MPA, MPH, and Anna M. Morenz, MD, about their recent JAMA Dermatology article, "Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities."
Dr. Schwarzenberger: You and your colleagues recently looked at the state of dermatologic care for American Indian individuals in rural communities. Please describe your study and your key findings.
Dr. Morenz: We sought to analyze access to dermatologic care for rural American Indian communities through geographic analysis and a telephone-based survey. In the first part of our study, we calculated how many dermatology clinics were located within a 35-mile radius of rural Indian Health Service (IHS) hospitals and how many were within a 90-mile radius. We found that in some IHS areas (Great Plains and Billings areas), most of the clinics were more than 90 miles away. In the Southwest, clinics are a bit closer but long driving distances are still most common, with no clinics located within 35 miles of the Albuquerque area rural hospitals and 2/7 dermatology clinics located within 35 miles of Navajo area hospitals. This reflects the heterogeneity of the health care system for rural American Indian people throughout the nation. We also telephone surveyed these nearest rural dermatology clinics to assess availability in terms of patient wait time, insurances accepted, etc. We found that a quarter of these clinics did not accept Medicaid, and a quarter did not accept IHS referrals for patients without insurance. Lastly, we surveyed teledermatology programs about partnerships with IHS sites and discovered a limited number of active collaborations.
Dr. Schwarzenberger: Were you surprised by any of the findings?
Dr. Morenz: Based on the clinical experiences that many of us have had with difficulty referring patients to dermatologic care (both for the access challenges mentioned above as well as the nuances of the IHS priority system for payment of referrals), we were largely not surprised by the findings. Nonetheless, the extent to which many clinics, despite being the closest ones to an IHS hospital, did not accept IHS referrals (25%) was disheartening. Another surprising finding was the number of teledermatology programs we surveyed that were no longer active despite being listed on the American Telemedicine Association website.
Dr. Schwarzenberger: Teledermatology seems like a great option for providing care to individuals in rural areas. Yet, you showed that a significant number of teledermatology programs are no longer active. While identifying the causes of these failures was beyond the scope of this study, do you have a sense of likely contributing factors?
Dr. Mostaghimi: It’s hard to know exactly what the barriers were in these specific scenarios. Generally speaking, while the cost of technology is becoming less prohibitive, significant regulatory barriers persist which can be costly and time consuming to overcome. It is also possible that a reduction in the number of teledermatology programs reflects a natural contraction and perhaps consolidation of a maturing industry.
Dr. Schwarzenberger: Could there be other factors beyond time, distance, and money that serve as impediments to dermatologic care in our American Indian communities?
Dr. Morenz: Absolutely! We highlight some of these in our discussion, but to underscore a few: First, mileage is a crude measurement of travel time, as many of the roads people must travel on reservations are slow-going dirt roads that can become impassable with rain. Trust in the health care system and in providers is a huge factor to highlight here as well. In addition to the history of extraction and forced removal from their homelands, American Indian people have faced unethical medical research performed without their consent (as have other minority groups in the US) and an approach to health care that has frequently been at odds with local, traditional beliefs and practices surrounding sickness and healing.
Dr. Schwarzenberger: Many American Indians receive care through Medicaid or the Indian Health Service. Of the clinics you surveyed, almost 70% did accept some form of Medicaid, which seems higher than the number of dermatologists nationwide who accept Medicaid. Couldn’t the skeptic suggest that this population has better access to care than many other individuals with similar insurance?
Dr. Morenz: One of the key pieces of this finding are the words “some form of Medicaid.” Medicaid varies by state and the extent to which Medicaid covers certain individuals and certain treatments varies widely. We found that several clinics only accept certain Medicaid plans within a state or only dual-eligible patients (on Medicare and Medicaid). Another limitation of optimistically interpreting this finding is that American Indian people are more likely to be insured by Medicaid than the general U.S. population (27% vs 25%), making the 25% non-acceptance rate for Medicaid a substantial barrier to access.
Dr. Schwarzenberger: How could we as a specialty come together to provide better care for this unique population?
Dr. Mostaghimi: Continued efforts by dermatologists through programs such as the Native American Health Service Resident Rotation program sponsored by the AAD or local efforts, such as those in our department at Brigham & Women’s Hospital can provide crucial partnerships to support front-line caregivers taking care of challenging patients. Through a combination of on-the-ground support and follow-up via physician-to-physician consultations, we can help train primary care physicians and support their efforts where dermatology care is limited.
Dr. Schwarzenberger: Finally, how did you become interested in this very important issue?
Dr. Mostaghimi: I rotated at the Northern Navajo Medical Center as a third-year medical student and worked with a family medicine doctor who ran an impressive, busy skin clinic to meet the demands for everything from basal cell carcinoma excisions, to severe psoriasis treatment, to UV therapy for cutaneous T-cell lymphoma. I was struck by the disparities in access and frequency of advanced dermatologic disease. Between my experiences here and on a dermatology rotation in Boston, I wanted to better understand access for patients living near rural Indian Health Service hospitals. I was fortunate to find fantastic mentors back at my home institution with experience in health services research in dermatology and front-line partnerships with the Indian Health Service who wanted to tackle this question with me.
Dr. Mostaghimi serves as assistant professor of dermatology, director of the inpatient dermatology consult service, and co-director of the Complex Medical Dermatology Fellowship at Brigham & Women’s Hospital, Harvard Medical School. Dr. Mostaghimi has no relevant financial or commercial interests to disclose. Dr. Morenz is a first-year internal medicine resident at the University of Washington, with an interest in improving access to both primary and specialty care for rural, underserved communities. Dr. Morenz has no relevant financial or commercial interests to disclose. Their article appeared in JAMA Dermatology. doi:10.1001/jamadermatol.2019.0872.
Disclaimer: The views and opinions expressed in this article do not necessarily reflect those of DW.
